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National Transportation Safety Board PB95-910405 NTSBIAAR-95/05 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT B RUNWAY COLLISION INVOLVING TRANS WORLD AIRLINES FLIGHT 427 AND SUPERIOR AVIATION CESSNA 441 BRIDGETON, MISSOURI NOVEMBER 22,1994 6519B The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L'Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NT SB/AAR-95/0 5 PB95-9 10405 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY COLLISION INVOLVING TRANS WORLD AIRLINES FLIGHT 427 AND SUPERIOR AVIATION CESSNA 441 BRIDGETON, MISSOURI NOVEMBER 22,1994 Adopted: August 30,1995 Notation 6519B Abstract: This report explains the runway collision of Trans World Airlines flight 427, a McDonnell Douglas DC-9-82, and N441KM, a Cessna 441, at the intersection of runway 30R and taxiway Romeo at the Lambert-St. Louis International Airport in Bridgeton, Missouri. The safety issues discussed in the report include aircraft lighting and conspicuity; airport markings, signs, and lighting; runway 3 1 designation, utilization, displaced threshold; ATC and pilot phraseology (specifically, the term "back-taxi"); pilot training; runway incursion detectiodprevention methods; and ASDE/AMASS development. Safety recommendations concerning some of these issues were made to the Federal Aviation Administration (FAA). CONTENTS EXECUTIVE SUMMARY ........................................ vi 1. FACTUAL INFORMATION ....................................... 1 1.1 History of the Flights ...................................... 1 1.2 Injuries to Persons ................................... 3 1.3 Damage to Airplane .................................. 4 1.4 OtherDamage ...................................... 4 1.5 Personnel Information ................................. 4 1.5.1 Trans World Airlines Crewmembers ....................... 4 1S.2 Captain Information .................................. 4 1.5.3 First Officer Information ............................... 4 1.5.4 Cessna 441 Pilot ..................................... 5 1.5.5 Cessna 441 Pilot-rated Passenger ......................... 5 1.5.6 STL Air Traffic Control Specialists ....................... 6 1.5.7 STL Local Controller ................................. 6 1.5.8 STL Ground Controller ................................ 6 1.6 Airplane Information .................................. 6 1.6.1 McDonnell Douglas MD-82 ............................. 6 1.6.2 Superior Aviation Cessna 441 ........................... 6 1.7 Meteorological Information ............................. 7 1.8 Aids to Navigation ................................... 7 1.9 Communications ..................................... 7 1.10 Airport Information .................................. 8 1.10.1 Airport Signs, Markings and Lighting ..................... 11 1.10.2 Runway 3 1 Information ............................... 11 1.10.3 Postaccident Airport Changes ........................... 13 1.10.4 ATC Tower ....................................... 13 1.10.5 Postaccident ATC Scheduling Changes .................... 14 1.11 Flight Recorders .................................... 14 1.12 Wreckage and Impact Information ....................... 15 1.12.1 Cessna 441 Wreckage Information ....................... 15 1.12.2 MD-82 Wreckage Information .......................... 18 1.13 Medical and Pathological Information ..................... 18 1.14 Fire ............................................. 20 1.15 Survival Aspects .................................... 20 1.15.1 Evacuation ....................................... 20 1.15.2 Emergency Response ................................ 20 1.15.3 Emergency Airport Closure ........................... 21 1.16 Tests and Research .................................. 21 ... 111 1.16.1 Night Conspicuity Tests .............................. 21 1.16.2 Runway Visibility Tests .............................. 22 1.16.3 Recorded Radar Data ................................ 22 1.16.4 Lighting Components, Cessna 44 1 ....................... 23 1.16.5 Communication Radios, Cessna 44 1 ...................... 23 1.16.6 MD-82 Accelerate-Stop Data ........................... 23 1.17 0rg ani zat ion a1 and Manage men t Inform at ion ................ 23 1.17.1 Superior Aviation ................................... 23 1.18 Additional Information ............................... 24 1,18.1 Automatic Terminal Information Service (ATIS) ............. 24 1.18.2 Air Traffic Handlinghnterviews ......................... 25 1.18.3 ASDE-3 Information ................................. 25 1.18.4 Airport Movement Area Safety System (AMASS) Information ... 26 1.18.5 Safety Board Actions -- Runway Incursion Issue ............. 26 2 . ANALYSIS . ................................................ 29 2.1 General .......................................... 29 2.2 Cessna 441 Pilot Performance .......................... 30 2.2.1 Scenario: Pilot Became Lost During Airport Ground Operations . 30 2.2.2 Alternate Scenario: Pilot's Preconception that Runway 30R was his Departure Runway ................................ 30 2.2.3 Communications., .................................. 32 2.3 MD-82 Flightcrew Performance ......................... 33 2.3.1 Airport Traffic Awareness ............................. 33 2.3.2 Conspicuity of Cessna 441 from the Runway 30R threshold ..... 34 2.4 Role of Air Traffic Control ............................ 37 2.4.1 Issuance of Taxi Clearance ............................ 37 2.4.2 Visual DetectiodTracking of Cessna 44 1 .................. 38 2.4.3 ATC Staffing and Workload ........................... 39 2.5 Airport Factors - Designation of Runway 31 ................ 40 2.6 Prevention of Runway Incursions ........................ 41 2.6.1 Pilot Training in Ground Operations ...................... 4 1 2.6.2 ASDEIAMASS .................................... 41 2.6.3 Other Runway Incursion Prevention Technology ............. 43 2.6.4 FAA Program Initiativesklanagement .................... 43 2.7 Survivability Aspects ................................ 45 2.7.1 Airport ClosureEmergency Operations ................... 45 2.7.2 Evacuation of the MD-82 ............................. 46 3 . CONCLUSIONS ................................................ 47 3.1 Findings ......................................... 47 3.2 Probable Cause ..................................... 48 4 . RECOMMENDATIONS ........................................... 49 IV 5 . APPENDIXES .................................................. 51 APPENDIX A .INVESTIGATION INFORMATION .................... 51 APPENDIX B . ATC TRANSCRIPT ............................... 53 APPENDIX C . CVR TRANSCRIPT ............................... 91 APPENDIX D .FDR DATA PRINTOUT ............................ 115 APPENDIX E .RADAR STUDY .................................. 121 APPENDIX F .MD-82 ACCELERATED STOP DATA .................. 127 APPENDIX G - RUNWAY INCURSION/GROUND COLLISION SAFETY RECOMMENDATIONS ................................... 129 APPENDIX H .FEBRUARY 28, 1995, RECOMMENDATIONS ........... 145 APPENDIX I .AIRPORT CLOSURE RECOMMENDATION .............. 153 V EXECUTIVE SUMMARY On November 22, 1994, at 2203 central standard time, Trans World Airlines flight 427, a McDonnell Douglas DC-9-82 (MD-82), N954U, collided with a Cessna 441, N441KM, at the intersection of runway 30R and taxiway Romeo, at the Lambert-St. Louis International Airport (STL) in Bridgeton, Missouri. The MD-82 was operating as a regularly scheduled passenger flight from STL to Denver, Colorado. The flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. There were 132 passengers, five flight attendants, and three flightcrew members aboard the airplane. The MD-82 sustained substantial damage during the collision. The Cessna 441, operated by Superior Aviation, Inc., as a 14 CFR Part 91 positioning flight, was destroyed. The commercial pilot and the passenger, who was rated as a private pilot, were the sole occupants on board the Cessna and were killed. Of the 140 persons on board the MD-82, eight passengers sustained minor injuries during the evacuation. The National Transportation Safety Board determines that the probable cause of this accident was: the Cessna 441 pilot's mistaken belief that his assigned departure runway was runway 30R, which resulted in his undetected entrance onto runway 30R, which was being used by the MD-82 for its departure. Contributing to the accident was the lack of Automatic Terminal Information Service and other air traffic control (ATC) information regarding the occasional
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